Aristacare At Park Avenue

F-F550 Resident Rights

Level of Harm - Minimal harm or 28 Pa. Code 201.14(a) Responsibility of licensee potential for actual harm 28 Pa. Code 201.18(b)(3) Management Residents Affected - Few

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 5 of 5 395588

F-F802 Sufficient Dietary Support Personnel

28 Pa. Code 201.14(a) Responsibility of licensee

28 Pa. Code 201.18(b)(3) Management

28 Pa. Code 211.12(d)(1)(5) Nursing Services

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 2 of 5 395588 Department of Health & Human Services Printed: 08/29/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 395588 B. Wing 04/11/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Embassy of Park Avenue 14714 Park Ave Extension Meadville, PA 16335

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0580 Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. Level of Harm - Minimal harm or potential for actual harm 47356

Residents Affected - Few Based on review of facility policy and clinical record, and staff interviews, it was determined that the facility failed to notify the resident's physician and emergency contact timely regarding a change in condition for one of 13 residents reviewed (Resident Resident R1).

Findings include:

The facility policy entitled Notification of Responsible Party and Physician Procedure, dated 10/28/24, indicated that the nurse should notify the Primary Care Physician when a resident has a significant change in clinical status such as a decline in condition, new/worsening symptoms, new/change in pain status The nurse or designee will notify the responsible party regarding change in the resident's clinical status

The clinical record revealed that Resident Resident R1's initial admitted was 1/17/23, with diagnoses including nstemi myocardial infarction (a serious heart attack causing damage related to a reduced blood supply to the heart), type II diabetes (when the body does not use insulin properly with poor blood sugar control), and muscle weakness.

The clinical record progress notes revealed that on 1/25/25, at 12:38 a.m. Resident Resident R1 was a little off and had slurred speech. The physician and emergency contact were not notified of these changes in condition timely.

During an interview on 4/11/25, at approximately 9:30 a.m. the Director of Nursing and Nursing Home Administrator confirmed that the physician and emergency contact should have been contacted and it should have been documented in the clinical record at the time of the slurred speech.

28 Pa. Code 201.14(a) Responsibility of licensee

28 Pa. Code 201.18(b)(1) Management

28 Pa. Code 211.12(d)(1)(5) Nursing services

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 3 of 5 395588 Department of Health & Human Services Printed: 08/29/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 395588 B. Wing 04/11/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Embassy of Park Avenue 14714 Park Ave Extension Meadville, PA 16335

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0802 Provide sufficient support personnel to safely and effectively carry out the functions of the food and nutrition service. Level of Harm - Minimal harm or potential for actual harm 48496

Residents Affected - Few Based on observations, review of facility records, and resident and staff interviews, it was determined that

the facility failed to provide sufficient staff to carry out the functions of the food and nutrition services in the kitchen.

Findings include:

Review of facility policy entitled Safe and Homelike Environment dated 10/28/25, indicated In accordance with residents' rights, the facility will provide a . comfortable and homelike environment .

Review of four weeks of dietary schedule lacked evidence that the appropriate number of trained dietary staff were scheduled each day.

Review of grievances revealed that residents going to dialysis did not have meal trays ready for residents to consume before going to dialysis.

Review of Resident Council meeting minutes and food committee minutes from 3/25/25, revealed resident concerns of food is warm or not hot.

Interviews on 4/9/25, between 10:00 a.m. and 1:00 p.m. with Residents Resident R1, Resident R2, Resident R3, Resident R4, Resident R5, Resident R6, Resident R7, Resident R8, Resident R9, and Resident R10 revealed that they are receiving meals in Styrofoam containers several days a week and the food is often cold as a result. Residents identified above revealed they are aware meals were being served in Styrofoam containers as a result of dietary staffing.

Interview on 4/9/25, at 11:40 a.m. with Resident Resident R11's family member revealed that they eat at the facility with Resident Resident R11 several days a week. They confirmed that meals are served in Styrofoam containers several days a week and the food is often cold as a result.

Interview on 4/9/25, at 12:50 p.m. with Dietary Aide Employee E2 revealed that dietary uses foam containers due to not having enough staff in the dietary department. He/she expressed that there have been several shifts that there had only been a cook and one dietary aide working.

Interview on 4/9/25, at 12:20 p.m. with the Dietary Manager Employee E3, revealed that the dietary department is not staffed adequately. He/she revealed there have been shifts when there are only two staff working in the dietary department. He/she also revealed that meals are served in Styrofoam containers when

the dietary department is not staffed adequately.

Interview on 4/9/25, at 1:30 p.m. with the Dietary Manager Employee E3, confirmed that Styrofoam containers are used for resident's meals due to staffing in the dietary department. He/she also confirmed that residents sitting at the same table for meals should be served at the same time.

Interview on 4/11/25, at 10:50 a.m. with the Nursing Home Administrator (NHA) he/she confirmed that staffing levels in the dietary department should be one cook and three dietary aides for each shift.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 4 of 5 395588 Department of Health & Human Services Printed: 08/29/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 395588 B. Wing 04/11/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Embassy of Park Avenue 14714 Park Ave Extension Meadville, PA 16335

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0802 Refer to